MULTI-SECTORAL NUTRITION STRATEGY 20142025

Technical Guidance Brief

COMMUNITY-BASED MANAGEMENT OF ACUTE

MALNUTRITION

In 2016, 156 million children under-5 suffered from stunting. The consequences are dire: a child with severe acute malnutrition (SAM) is 11.6 times more likely to die, and a child with moderate acute malnutrition (MAM) is 3 times more likely to die than a well-nourished child (Olofin, 2013).1 Acute malnutrition is characterized by rapid weight loss and/or nutritional edema2 caused by illness and/or inadequate food intake, such as a sudden change in the quality and/or quantity of food or poor infant feeding practices. It often increases during humanitarian crises but occurs during non-emergency situations as well.

Among children under-5 worldwide, 50 million children suffered from wasting in 2016. The Lancet series identified 10 high-impact, nutrition-specific interventions that, if taken as a package to 90 percent coverage, could reduce wasting by 60 percent and stunting3 by 20 percent (Bhutta, 2015). The management of SAM and MAM are 2 of the 10 interventions. Community Management of Acute Malnutrition (CMAM) is a proven approach to manage SAM and MAM in children under 5 and is currently implemented in more than

CMAM 70 countries classifies S(UNICEF, AM in ch2013). ildren as complicated or uncomplicated.Complicated SAM cases, which represent approximately 1020 percent of all children with SAM, refer to children without an appetite and/or with medical complications such as a high fever, severe dehydration, and lower respiratory infection. The children are stabilized in 24-hour inpatient care facilities before referral to continue treatment at decentralized outpatient care facilities. Uncomplicated SAM cases refer to children with no medical complications and with an appetite. These children are managed at home with weekly or biweekly visits at a nearby health facility. All children receive essential medical care as part of the management of malnutrition. Community-based mobilization, screening, follow-up, counseling, and education are a cornerstone of CMAM, allowing for earlier detection of malnutrition, continuous monitoring of care, and linkages with other services. By offering case management at decentralized sites and incorporating community activities, the approach increases coverage, access, and effectiveness of treatment for acute malnutrition.

Definitions of SAM and MAM

Acute malnutrition is measured by:

low weight-for-height index, also called wasting low mid-upper arm

circumference (MUAC) nutritional edema

Severe acute malnutrition is defined by a weight-for-height index

Community-Based Management of Acute Malnutrition Technical Guidance Brief

HISTORY OF CMAM

Prior to CMAM, children with SAM were treated in inpatient facilities with therapeutic milks, commercially called F75 and F100 (see section on nutrition products). The inpatient model posed many challenges to effective treatment for both health systems and patients long recovery periods (up to 6 weeks); overcrowding and cross-infection; high opportunity costs for families to access and remain in treatment; costly and resource-intensive services for health systems to sustain; concerns about safe preparation and storage of therapeutic milks; and low coverage of services. In the mid-1990s, ready-to-use therapeutic food (RUTF) was developed as an alternative to therapeutic milk (F100) that could be safely consumed at home. This innovative product allowed treatment for uncomplicated cases of SAM to be shifted to the home, paving the way for CMAM. The first pilot project tested the CMAM approach in 2000 during humanitarian emergencies (Collins, 2002). It was found to be so effective that it was endorsed by United Nations (U.N.) agencies in 2007 (WHO et al., 2007) and is now considered the standard of care for managing acute malnutrition in emergency and development contexts.

COMPONENTS OF CMAM

The CMAM approach is comprised of four components: (1) community outreach and mobilization; (2) outpatient management of SAM without medical complications; (3) inpatient management of SAM with medical complications; and (4) services or programs to manage moderate acute malnutrition (MAM), such a supplementary feeding program (see textbox on the client flow in a comprehensive CMAM approach). Implementation of the various components of CMAM can vary across geographic areas and implementers, but all CMAM programs include the outpatient management of SAM without medical complications and are designed with a community component. Some national protocols have special consideration for people living with HIV and/or tuberculosis (TB), and include older age groups (e.g., in Mozambique).

Some CMAM programs include MAM management, while others do not. This is partly a reflection of the absence of normative global guidance for MAM management, compared to SAM management for which normative guidance is readily available.4 Resources may also be more constrained for managing MAM, which has a lower risk of death compared to SAM and, therefore, may be deemed a lower priority. Given the high global burden of MAM (an estimated 33 million children) (UNICEF et al., 2012) and the fact that the prevention and treatment of MAM reduce the incidence and severity of SAM, it is important for CMAM programs to consider incorporating MAM management and prevention either as part of the CMAM program itself or through links with complementary programs.

The management of acute malnutrition in infants under 6 months, a highly vulnerable group with an increased risk of mortality, is generally included in national protocols, though stronger evidence-based guidance is needed. The current focus is on inpatient treatment for infants while supporting

4 See guidance documents for SAM management listed under References in this brief.

2

Client Flow in a Comprehensive CMAM Approach

A comprehensive CMAM approach will vary by context, but the client flow will likely involve these steps:

Community-based health workers screen children for acute malnutrition using mid-upper arm circumference tapes and refer those identified with SAM or MAM to the nearest health center.

If a child is identified as acutely malnourished, the caretaker takes the child to the health center where the health worker conducts further screening and diagnosis according to the established protocol. The health worker takes anthropometric measurements and checks for nutritional edema, appetite, and other medical complications. At the health center, the staff also screens other children that have come for pediatric visits.

If the child has SAM and medical complications or no appetite, the child is admitted to inpatient treatment using therapeutic milks until the complications have stabilized and the child can be transitioned to outpatient care.

If the child has SAM, no medical complications, and an appetite, the child is treated on an outpatient basis with RUTF.

If the child has MAM, the child might receive a specialized food product, such as ready-to-use supplementary food (RUSF) or fortified blended food (FBF).

Once home, the child receives visits from the community-based health worker to check on his/her status and receive counseling, education, and possibly referrals to complementary programs. The child stays in the program until he/she reaches exit criteria, though defaulting (not completing the full course of treatment) is a challenge that most programs face.

Community-Based Management of Acute Malnutrition Technical Guidance Brief

breastfeeding; infants under 6 months with acute malnutrition do not receive RUTF.

NUTRITION PRODUCTS USED IN THE MANAGEMENT OF ACUTE MALNUTRITION National treatment protocols for the management of acute malnutrition include essential medical treatment such as antibiotics, vitamin A supplements, malaria prophylaxis, deworming treatment, measles vaccination, and iron or folic acid supplements, as well as the following specialized nutrition products:

RUTF is a lipid-based, energy-dense, mineral and vitaminenriched food specifically designed to treat SAM in children 6 to 59 months. RUTF has a similar nutrient composition to F100, does not require cooking, and is safe for in-home consumption.

RUSF has similar properties to RUTF, but one of its formulations is specifically designed to treat MAM in children 6 to 59 months.

FBF are blends of partially precooked and milled cereals, soya, beans, and pulses fortified with vitamins and minerals, and may contain vegetable oil or milk powder.

F75 and F100 are therapeutic milks used in inpatient treatment of SAM. They provide 75 and 100 kilocalories for every 100 milliliters, respectively.

Rehydration solution for malnutrition (ReSoMal) is oral rehydration solution specifically for severely malnourished children.

Combined Mineral and Vitamin Mix is used to make F75 and F100 therapeutic milks from l ocal ingredients (milk, oil, and sugar), and ReSoMal from the commonly-available oral rehydration solution.

RUTF, RUSF, and FBF are further described in the below product table, along with specialized nutrition products for the prevention of malnutrition and for temporary meal replacements (Global Nutrition Cluster, 2014).

CONSIDERATIONS FOR SUPPORTING CMAM

CMAM integration into the national health systems. In nearly all countries, CMAM services are delivered as part of regular health services or as a combination of regular and emergency services. Although most ministries of health assume leadership and coordination roles and have established partnership